Inspection on 18/03/08 for Highgrove

This inspection was carried out on 18th March 2008.

CSCI found this care home to be providing an Poor service.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Highgrove 22/10/07

Highgrove 05/05/06

Highgrove 06/10/05

Highgrove 07/04/05

Highgrove 10/09/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Highgrove Stapehill Road Stapehill Wimborne Dorset BH21 7NF Lead Inspector John Hurley Unannounced Inspection 18th March 2008 09.30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Highgrove DS0000061344.V361261.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Highgrove DS0000061344.V361261.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Highgrove Address Stapehill Road Stapehill Wimborne Dorset BH21 7NF 01202 875614 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Samily Care Ltd ****Post Vacant**** Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21) of places Highgrove DS0000061344.V361261.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd October 2007 Brief Description of the Service: Highgrove has been operational as a care home since 1991, the present owners Mr & Mrs Bleach have been registered since June 2004 under the company name of Samily Care Ltd. The registered manager post is currently vacant. The home is registered to accommodate 21 older persons for personal care only. The property is a large Victorian house that has been extended and is set in large, well-maintained gardens. The front of the home provides off road parking for several cars. Highgrove is in Stapehill between the towns of Ferndown and Wimborne and is a short walk from the local bus route and post office. Accommodation is provided on ground and first floor levels, the first floor is accessible by a central stairway, there is no lift. Catering and laundry services are provided. The current level of fees for personal care and services and accommodation at Highgrove is between £420 and £520. Highgrove DS0000061344.V361261.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means the people who use this service experience poor quality outcomes. This unannounced inspection took place on 18th March 2008 between 09.30 and 17.00; this was the second key inspection of this home in the last 12 months. The last inspection in October 2007 resulted in 6 requirements being repeated from previous inspections and a further 5 being made. The purpose of this key inspection was to check that the residents living in the home were safe and properly cared for and to review progress in meeting the 11 requirements and recommendations made at previous inspections. The registered manager left employment in 2007; the current manager is the second to fill this vacancy although is not yet registered with the Commission. Both the manager and owner (Mrs Bleach), Responsible Individual for Samily Care Ltd were available throughout the inspection. Two inspectors visited the home for this inspection, relevant records and medication systems were examined, staff and residents were spoken with and a tour of the premises completed this inspection What the service does well: What has improved since the last inspection? A person has been appointed to manage the home since the last inspection, this person has experience in managing a care home although has not been registered with the Commission. Highgrove has experienced some difficulty in Highgrove DS0000061344.V361261.R01.S.doc Version 5.2 Page 6 obtaining and retaining a suitable manager and it is acknowledged that the current manager has entered Highgrove at a time when there is a substantial amount of work to be done to ensure it meets the expected standards; it is therefore necessary for work to be prioritised and for the manager to be supported by the registered providers during this time. The manager has introduced new assessment and care planning documentation which, if used appropriately will provide for a systematic approach to care delivery. The review of staff files and staff training profiles with the introduction of staff supervision has also been positive. Residents have benefited also from more robust management of their personal finances; a requirement of the last inspection has been addressed in respect of this. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Highgrove DS0000061344.V361261.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Highgrove DS0000061344.V361261.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 (Standard 6 is not applicable) Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Highgrove continues to fail to achieve this standard and continues to be in breach of the regulations in respect of carrying out full assessments of prospective residents before they make a decision to move to the home. EVIDENCE: The last inspection report dated 22nd October 2007 made the requirement that ‘All service users must have a full and comprehensive assessment of need prior to entering the home’ (NMS OP3); this requirement is repeated as the inspection evidenced that this standard is not met. The manager confirmed that one resident had moved to the home since the last inspection, examination of this person’s care records evidenced that the pre-admission assessment form had not been fully completed and did not provide sufficient detail of the persons care needs in order that the assessor could establish whether the home had the services and facilities to care for the resident. Highgrove DS0000061344.V361261.R01.S.doc Version 5.2 Page 9 Highgrove DS0000061344.V361261.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Highgrove continues to fail to achieve these standards and continues to be in breach of the regulations in respect of planning a systematic approach to meeting residents’ personal welfare and health care needs and to appropriately manage medication in the best interests of residents. EVIDENCE: The last inspection report dated 22nd October 2007 made the requirements that: ‘All service uses must have a full and comprehensive assessment on which to base an individualised plan of care that must be followed in order that care needs can be met and risks reduced or eliminated. Service users must be consulted with regard to the decision-making processes of assessment and care planning’ (NMS OP7) This requirement was first made at the inspection dated 07.04.05 and was repeated at the inspection of 05.05.06 and 22.10.07. Highgrove DS0000061344.V361261.R01.S.doc Version 5.2 Page 11 The timescale for action was 31.12.07 – no action plan was received and this inspection evidenced that the standard has not been achieved (See below) ‘A record must be held indicating the amounts of all medicines received into the home including the date and signature of the staff member responsible. Medicine records and audit trails must be regularly monitored, the outcome and action taken recorded to ensure that medicines are given as prescribed and accurately recorded. The medication policy must be updated so that staff have clear procedures to follow on all aspects of handling medication’.(NMS OP9) This requirement was first made at the inspection dated 23/03/07, again at the last inspection and is now repeated for the third time. The timescale for action was 31.12.07 – no action plan was received and this inspection evidenced that the standard has not been achieved (See below) Six resident care files were examined; the following was noted: File 1 – of a resident admitted to the home in October 2007, the preadmission assessment was not fully complete and there was no care plan in place. The manager confirmed that she was working on this care plan currently and printed a copy from the computer for the inspector. It remains the case however that this resident had been living at Highgrove for nearly six months with no plan of care or instruction for staff indicating how needs were to be met. File 2 - of a resident who has a diagnosis of diabetes, this residents care file was reviewed at the last inspection which noted that ‘One resident with a care plan specifically relating to diabetes stated that glucose levels should be tested 6 monthly, the record held identified one recording in January 2007 at 12.00 where the reading was 2.8; there was no record of the normal parameters of this persons levels or what action staff should take if it falls outside these parameters. One record relating to urinalysis was held dated March 2007, the next test was marked as being needed in June 2007, this had not been done’. This inspection evidenced that there had been no review of this person’s diabetic care regime or any routine testing. Since the last inspection a new file has been made in which monitoring charts are held for residents, there was no monitoring chart for this resident in respect of diabetes. File 3 - of a resident who was in receipt of wound care from a visiting district nurse. This resident’s care plan informed staff to provide a weekly bath using the hoist, the care plan gave no instruction to staff concerning management of the wound site or the dressing during bathing. A care plan for this resident also referred to management of occasional urinary incontinence although the assessment for this resident in relation to elimination, and confirmed by a member of care staff when asked indicated that this resident was doubly incontinent; there was no reference to faecal incontinence or its management Highgrove DS0000061344.V361261.R01.S.doc Version 5.2 Page 12 in the care plan. An assessment for this resident indicating general dependency levels indicated that a significant deterioration in health and general well-being had occurred in the past 18 months since admission, there was no indication of how this deterioration had been managed or what professional advice had been sought. File 4 – of a resident whose assessments and care plans indicated a high degree of independence although an ongoing episode of ill health had been referred to the resident’s daughter to manage; there was no indication of what the staff had done at Highgrove to support this resident or to seek appropriate, professional advice and treatment. File 5 – of a resident for whom staff entries in the daily record and the care plans indicated a form of dementia. Records indicated that the resident had a tendency to ‘wander’ and the care plan referred to episodes of inappropriate behaviour with regard to use of the commode. There was no action plan in place to inform staff how this resident should be assisted in relation to confusion, mental health or psychological welfare. Highgrove is not registered to accommodate residents with dementia type illnesses. File 6 – of a resident who has assistance with funding arrangements and as such has a social service care plan in respect of the placement at Highgrove. This care plan indicated that the resident’s meals have to be cut up (to assist swallowing/prevent choking) the care plan drawn up by Highgrove informs staff that the resident ‘needs prompting’. The community care plan also states that the resident’s weight must be monitored monthly; the record of this resident’s weight as monitored by Highgrove indicates a loss of 27lbs in 12 months, there was no record of any evaluation of this weight loss or action taken to seek professional advice regarding this. The requirement of the last inspection is again repeated and continued breaches will lead to futher enforcement action being taken by the Commission. Medication systems were reviewed. The home has changed pharmacist and introduced a new medication recording system. Although this had only been in use for two days one record was not completed to indicate if medication had been administered or not. The inspector looked at the previous recording sheets that suggested that these records were not robust; confirmation of receipt of medicines into the home is tenuous as some were not signed in and some were not recorded as to the quantity received; there is therefore no audit trail of all medicines received into the home. It was also found that where residents are prescribed a medicine to be given ‘when required’ there is no rationale recorded for why or when this should be Highgrove DS0000061344.V361261.R01.S.doc Version 5.2 Page 13 given. Instructions on medication administration records for one preparation state that “ It is recommended that this medicine is only given when the pulse rate is over 60”, one resident for whom this is prescribed has a pulse rate recorded before administration, another did not. Temazepam, a medicine classified for the purposes of storage in the home as a controlled drug is not sufficiently recorded. The controlled drugs register evidenced a number of errors being made in the recording of this medication. There were some gaps in the recording of medicines administered to residents. Staff were seen to approach residents respectfully and in a caring manner, meaningful dialogue with residents was limited as many had degrees of confusion. Staff were discrete when providing personal care. The residents informed the inspector that staff help them in a way that they wish and allow them to do as much or as little as they feel they can. Highgrove DS0000061344.V361261.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The last inspection made the judgement that: ‘The absence of up to date care planning documentation for service users leaves staff without formalised action plans to follow in order that each service users assessed needs in relation to social, cultural, religious and recreational activities are met, this also limits evidence that residents are able to exercise choice and control over their lives’. Family and friends are able to visit at any time. The absence of nutritional assessments and insufficient monitoring af residents weight leaves staff without proper instruction on each residents dietary requirements and how these are to be met. EVIDENCE: The last inspection reported that care planning documentation did not address individual residents personal preferences for chosen activities. A review of six Highgrove DS0000061344.V361261.R01.S.doc Version 5.2 Page 15 care files during this inspection found also that there was no record of individual preferences for social, recreational and cultural activity in the home. This inspection also noted that several residents with high levels of confusion were not stimulated and staff were unable to engage residents in meaningful activity suited to their individual needs and capabilities. Care records and the home’s visitors book indicated the extent to which family and visitors are welcomed into the home. Records of food provided and the kitchens were satisfactory and it was evident that residents are provided with choices. Resident care files examined did not hold comprehensive assessments with regard to residents’ dietary requirements or nutrition. One resident was noted to have lost a significant amount of weight in the past 12 months although there was no evaluation of this or referral for professional advice; one resident had a community based care plan stating explicitly that food had to be cut up, the care plan devised by Highgrove for this resident informed staff to ‘prompt’ the resident at mealtimes. Highgrove DS0000061344.V361261.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Policies and procedures are in place to protect the residents living at the home although to ensure that any incidents will be managed appropriately staff training in adult protection needs to continue. EVIDENCE: A complaints procedure is available to residents and visitors to the home. This details the action necessary should any complaints be received; The manager confirmed that no complaints have been received. The manager also confirmed that an adult protection policy is in place with procedures detailed for contacting the appropriate authorities should any concerns or allegations be made and that this had not changed since the last inspection, the procedure was not examined as part of this visit. Highgrove DS0000061344.V361261.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 25 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents live in comfortable, clean surroundings which are well maintained although their safety is compromised by poor infection control procedures EVIDENCE: There is evidence of investment around the home with general maintenance, decoration and refurbishment and residents live in comfortable, warm surroundings with a domestic, homely feel. The home’s laundry provides adequate facilities. A review of soiled linen storage in the home has been made since the last inspection. This has resulted in the home not following good infection control procedures as the soiled linen is now stored in containers that are not suitable as the containers have large holes in them as part of their design. This has resulted in a requirement being made at this inspection concerning infection control procedures (See standard 38) Highgrove DS0000061344.V361261.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sufficient numbers of staff are on duty in order to meet residents needs. Training is provided to staff in order that they have the skills and are competent to do their jobs. Staff recruitment practice is satisfactory. EVIDENCE: The last inspection reported sufficient numbers of staff on duty, rotas were not examined during this visit although the manager confirmed that staffing levels remain stable. The staff the inspector spoke with confirmed that they felt there are enough staff on duty, but the mornings can be busy. Staff training files examined were in good order and demonstrated that all staff have undertaken necessary statutory training courses and some other complimentary training events to ensure they are kept up to date with their skills and knowledge. Staff recruitment files examined evidenced that appropriate procedures are followed to ensure that prospective employees are suitable to work with vulnerable adults including obtaining CRB and POVA checks and suitable references. Highgrove DS0000061344.V361261.R01.S.doc Version 5.2 Page 19 Highgrove DS0000061344.V361261.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The last inspection resulted in the judgement that: Management of the home needs reviewing to ensure it is run in the best interests of residents. Whilst this inspection noted there to be some improvement and appointment of a manager, it is necessary for the registered persons to put forward a suitable manager for registration with the Commission in order to ensure accountability and maintain consistency. EVIDENCE: Since the last inspection when no manager was in post, a person, referred to in throughout this report as ‘the manager’ has been appointed. This person however, has not yet applied to the Commission for registration into this post Highgrove DS0000061344.V361261.R01.S.doc Version 5.2 Page 21 leaving Highgrove without an accountable leader who can provide direction for improvement and development. Highgrove has not been considered a ‘good’ home receiving many requirements over past inspections, this inspection has compounded that and issues raised and repeated breaches will lead to further enforcement action. The manager has experience managing (although not registered) another home and is in the process of completing the NVQ level 4 in management of care There are no quality assurance systems in place, although the registered providers have this in hand. They will be introducing new tools to ensure that the service is regularly monitored and evaluated and that plans for improvement can be developed. A requirement of the last inspection has been addressed in respect of the home’s management of residents personal finances. Examination of records relating to the handling of resident’s money showed these to be in order. Records were held relating to the income, receipt and balances held and any purchases made on behalf of the resident. A record is held relating to staff supervision, staff receive formal supervision at regular 3 monthly intervals and staff meetings take place every 2 months. Staff operation of the home’s laundry have been revised and new laundry baskets have been purchased since the last inspection, it was noted however that the basket marked ‘soiled’ laundry was not airtight and had no lid; In bathrooms around the home, fabric hand towels were in use. These two issues compromise the home’s safety in relation to the control of infection. Highgrove DS0000061344.V361261.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 1 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X 1 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X 3 3 X 1 Highgrove DS0000061344.V361261.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14 Requirement Timescale for action 2. OP7 14 & 15 3. OP9 13 All service users must have a full 03/06/08 and comprehensive assessment of need prior to entering the home. Time-scale 31/12/07 not met. This is the second inspection that has made this requirement. All service uses must have a full 03/06/08 and comprehensive assessment on which to base an individualised plan of care that must be followed in order that care needs can be met and risks reduced or eliminated. Service users must be consulted with regard to the decision-making processes of assessment and care planning. Time-scale 31/12/07 not met. This is the third inspection that has made this requirement, failure to address this issue. A record must be held indicating 03/06/08 the amounts of all medicines received into the home including the date and signature of the staff member responsible. Medicine records and audit trails DS0000061344.V361261.R01.S.doc Version 5.2 Page 24 Highgrove must be regularly monitored, the outcome and action taken recorded to ensure that medicines are given as prescribed and accurately recorded. The medication policy must be updated so that staff have clear procedures to follow on all aspects of handling medication. Time-scale 31/12/07 not met. This is the third inspection that has made this requirement. The Registered Person must make arrangements for the recording, handling, safekeeping and safe administration of medicines received in the care home including: Ensuring that medicines are prepared, administered and recorded one resident at a time to limit the risk of medication errors. 4. OP9 13(2) 03/06/08 5. OP33 24 Time-scale 31/12/07 not met. This is the second inspection that has made this requirement. The registered persons must 03/06/08 establish and maintain a system for reviewing and improving the quality of care in the home, a report of any such review must be provided to the Commission and be available to service users. This requirement was first made at the inspection-dated 05.05.06 and is repeated for the third time. Soiled laundry must be held in containers without holes and with lids and disposable hand towels must be provided to aid control of infection. DS0000061344.V361261.R01.S.doc 6. OP38 13 03/06/08 Highgrove Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP3 Good Practice Recommendations It is recommended that where residents are asked to sign their pre-admission assessment information that this is done following their participation in the process and that they have a full understanding of the implications of the assessment. This recommendation is repeated from the last inspection. It is recommended that social care plans are formulated for residents that identify, following assessment, how their individual social, recreational, cultural and religious needs can be met. This recommendation is repeated from the last inspection. It is recommended that access to the rear garden through the patio doors is assessed and advice sought on control measures that could be used to reduce risks associated with the two steps into the garden. This recommendation is repeated from the last inspection as it was not assessed during this visit It is recommended that the Responsible Individual ensures that she addresses the homes compliance with the Care Homes Regulations and the expected standards as part of her monthly visits to report on the conduct of the home. This recommendation is repeated from the last inspection as it was not assessed during this visit The record of fire drills and evacuation should be extended to include detail of who took part and how long the process took. This recommendation is repeated from the last inspection as it was not assessed during this visit 2. OP12 3. OP20 4. OP33 5. OP38 Highgrove DS0000061344.V361261.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Highgrove DS0000061344.V361261.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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